Sunday, August 27, 2017
When a number of medical or psychological symptoms tend to be seen together, that group of symptoms is referred to as a syndrome. Not every symptom that belongs to a syndrome occurs in every case, and symptoms can belong to more than one syndrome. (For instance, having a fever can be part of many medical syndromes, and being anxious can be part of more than one psychological syndrome.) In some cases, more than one cause could create the same pattern of symptoms.
Usually when people talk about a syndrome, they are referring to the symptoms experienced by a person suffering from a problem. But it makes just as much sense in some cases to talk about a syndrome of behavior shown by people who are not experiencing, but causing, someone else’s discomfort.
I’ve referred a number of times on this blog to a pattern of behaviors of parents toward children, a pattern often described in journalists’ reports of child abuse and neglect cases. This pattern usually includes some or all of the following: keeping children isolated or secluded in a less-used part of the house like a basement or attic, removing or not supplying furniture like beds, limiting the food children are given, claiming homeschooling but in fact not providing education, limiting toilet access, and requiring tedious and unnecessary physical work or exercise. There may or may not be physical punishment, and when there is it may include or be confined to “hot-saucing” or forcing other kinds of noxious food, or forcing liquids.
I propose to call this pattern of parental behavior maltreatment syndrome. Please note that I am simply proposing the existence of this pattern as an identifiable syndrome; I am not claiming that this is a well-known term or one that can be used authoritatively or diagnostically. However, it seems to me that the pattern crops up so often that it would be fruitful to regard it as a syndrome.
Although discussions of many syndromes include references to causes of the syndrome, in this case a specific cause may be difficult to pinpoint unless we have a good deal of detailed information about a case. However, I would suggest that there are two major causes of maltreatment syndrome. One involves learning or personal experience of some “old-fashioned” punishment methods, and implementation of those methods by parents who may be intellectually challenged or suffering from some form of mental or physical illness that limits their capacity for empathy and for recognition of consequences of their behavior. The other possible cause of maltreatment syndrome is direct instruction, through classes, reading, or personal contacts, about the parenting methods advocated by Nancy Thomas, the former dog trainer and currently self-identified trainer of foster parents. Thomas’s ideas, like those of her mentor Foster Cline in the 1990s, emphasize goals of child obedience and complete parental authority, to be achieved by whatever means of child control are necessary. These goals are presented as essential ways to prevent a child from becoming a serial killer or a prostitute (these being seen as equally evil by Thomas and Cline).
Which cause is at work in any specific case? This is something we could only know by examining the beliefs and experiences of the maltreating parents whose children have been found to be injured or killed by elements of maltreatment syndrome. Unless law enforcement and child protective services investigate these issues, it is impossible to know why parents chose the actions they did—and it is rare for the authorities to do this kind of investigation, possibly because they see the maltreatment as a series of undesirable acts rather than as a pattern.
Here is a recent example of behaviors that combine to create maltreatment syndrome: http://gephardtdaily.com/top-stories/roy-couple-accused-of-holding-children-captive-in-squalid-home-accepts-plea-deal/. A second article about this case is at www.desertnews.com/article/865678586/Judge-recuses-himself-in-disturbing-Roy-child-abuse-case.html.
In this case, a Utah couple by the name of Waldmiller have been identified as maltreating their three adopted sons, ages 7 to 11. I would identify their behavior toward the children as maltreatment syndrome. The Waldmillers kept the children for as much as 13 hours a day in a room with no lights, with windows screwed shut and painted black. They bound the children with zip ties and sometimes duct-taped their mouths. If they cried when beaten, their clothes were taken away. They were given limited food and had been punished for searching for food in the dumpster of a nearby school. They were sometimes punished by being made to eat heavily- salted rice with cayenne pepper and having water limited. To complete the maltreatment syndrome picture, the boys were not given access to toilet facilities and used a heating vent instead. They were also required to do exercises like squats to earn permission to read, and reading was required for them to be permitted to eat.
The Waldmillers did not go to trial but pled guilty to reduced child abuse charges. This means that there was no opportunity for full investigation of their motives and no public discussion of the beliefs behind their actions—whether these were simply what they remembered their parents doing, or techniques they had learned through Nancy Thomas instruction. Given the expense of investigations and trials, this is a common occurrence in cases of this kind, which in turn makes a fuller understanding of maltreatment syndrome impossible. Without a trial, there is no complete public record of the proceedings, and people concerned with the abusive pattern must rely on journalists’ reports of cases.
The lack of information about this parental behavior means that I can only suggest that the pattern be called maltreatment syndrome; I can’t say confidently that there is such a thing. I base my suggestion on years of journalists’ reports and on the reports of a small number of adults who experienced this kind of maltreatment pattern as children and are willing to talk about it. Unfortunately, not much more will be known until law enforcement and child protective services staff are aware at least of the concept of a maltreatment pattern that overlaps only slightly with other known patterns. Considering abusive acts one by one meets the requirements of the law, but misses the insights that can come from consideration of a syndrome.
Saturday, August 26, 2017
When family members feel that a child’s mental health is problematic, they may often delay finding treatment because they don’t know how to find a good therapist. Blogs like this one may even have scared them by pointing out that not all practitioners are helpful, and that some have even been harmful!
Here’s a newly-furbished website that provides a lot of helpful information about choosing a therapist and figuring out whether a treatment is effective: http://effectivechildtherapy.org. This website is created and maintained by the Society for Clinical Child and Adolescent Psychology (SCCAP), a division of the American Psychological Association.
Effectivechildtherapy.org offers some links to groups that list names and contact information for professional psychologists, but even more importantly, it offers information that is hard for parents to find, about how people decide whether a treatment is effective and whether a therapist has the training needed for the job.
Psychotherapies can be evaluated in terms of the evidence for their effectiveness. The issue is not simply whether a treatment IS or IS NOT effective, but how confident we can be that a claim of effectiveness is correct. Very few practitioners would decide to keep using a treatment if they thought it didn’t work—but how certain can they be that their decision for or against use is the right one? That decision should depend on evidence, but what kind? The evidence people bring forward may range from the highest level of systematic investigation down to a few anecdotes or testimonials. All of these are in some broad sense evidence, but they are not all equally supportive of confidence in a treatment choice.
Effectivechildtherapy.org includes a section that describes the levels of evidence (and therefore confidence) that may apply to particular therapies. There are a lot of different ways to describe levels of evidence, but effectivechildtherapy.org uses a method that ranks treatments from 1—the highest level of evidence and confidence—down to 5.
Level 1 treatments (sometimes referred to as Evidence Based Therapies, EBTs) have been supported by at least two studies that meet certain criteria. The studies are independent—not carried out by the same group of researchers. They involve randomized designs, in which child or adult clients who seek help are assigned randomly (i.e., without regard to their choices or other characteristics) to a treatment group or to some other comparison group; the other group could receive the usual care they would get in their community, or another treatment known to be effective, or some other arrangement. The use of a comparison group is especially important when studying child psychotherapies, because children’s moods and behavior may change as they mature, whether they are receiving treatment or not. Without a comparison group, researchers might accidentally conclude that the treatment caused any changes the children experienced; with a comparison group, it’s possible to tell the difference between effects of a treatment and effects of growth and maturation.
Effectivechildtherapy.org describes level 2 treatments as involving less evidence than was the case for level 1. Level 2 treatments are described as “probably efficacious”. There may be only one study showing that a level 2 treatment works better than an established treatment, or there may be two studies showing that it works better than no treatment. (Keep in mind, though, that there are general factors shared by various therapies, such as a warm relationship with a therapist, and that these tend to be helpful to people receiving treatment. For a treatment to work better than no treatment may mean that there is nothing special about the particular treatment, just that it shares those general factors.)
Level 3 treatments are described as “possibly efficacious”. One of these treatments might be supported by one study showing that the treatment worked better than no treatment, or by several small studies that did not include design factors like randomization.
Level 4 treatments are untested or experimental methods that are being used but cannot be claimed with confidence to be effective.
Level 5 treatments have been tested and either not shown to work, or have been tested and shown not to work but to actually make problems worse. More evidence from further research in the future may lead to a more encouraging conclusion, but at this point it is better not to choose a level 5 treatment.
Please notice that none of these levels of evidence depends on anecdotes or testimonials. When proponents of a treatment try to use testimonials to argue that their treatment is effective, they are admitting that they do not have the kind of research evidence that would get their methods listed at effectivechildtherapy.org.
So how do parents know which treatments are evaluated at which level? To do this would require reading all the research studies related to a treatment, and that’s a task that most parents will have neither the time nor the expertise to do. That’s exactly the reason why effectivechildtherapies.org was developed, and why it lists a variety of specific treatments which research evidence has placed at level 1. Effectivechildtherapies.org is directed primarily to parents of school-age children and of adolescents. ( The treatments listed are usually not focused on infants or toddlers.) The site has a helpful search function that enables users to look for information about specific problems or treatments and to find videos that are useful for parents.
If you are thinking about finding treatment for a child or family problem, have a look at http://effectivechildtherapy.org. It’s really helpful.
Tuesday, August 8, 2017
So hard to tell why people do the things they do—and when it comes to child abuse, their actions can be especially hard to explain. Everyone who has brought up children knows that there are risk factors for mistreatment. A bad day, an argument with another adults, a child who suddenly acts up, more stress than usual, a headache—these can all add up to at least the impulse to hurt a child. Fortunately for children, most of us, most of the time, have enough self-control to resist that impulse. And, having experienced the impulse, we recognize what might happen when an adult is overwhelmed by life and the intense desire to lash out at a child.
What’s much harder to understand is the systematic abuse and neglect that in some cases go on for years, and in other cases end with the child’s death. These situations are very different from the impulsive smack to the head or the rear. They would seem to require strong motivation and intentions to mistreat a child on a daily, even hourly, basis. Rather than from a momentary lapse in impulse control, these surely stem from a lack of empathy or concern, from a belief that children are property with no rights as human beings, and/or from a conviction that only a stern and painful upbringing can create “character” and insure a productive adulthood. The latter two points may result from the adults’ own childhood experiences and their unexamined acceptance of the views of their own families, sometimes expressed in phrases like “I was always brought up to…” or “My daddy always [fill in blank] and I turned out all right , didn’t I?” (by the way, it is never advisable to point out to that person that he did not actually turn out all right!).
When people who mistreat children point proudly to their family history as justification for their actions, we should be reminded of the fact that historically, children have been punished, or simply brought up, in ways that we now regard as abusive. Locking children in dark closets, washing out their mouths with blistering lye soap, making bed-wetters wash their sheets in icy cold water, withholding food—all of these are part of traditions that go back hundreds of years (although not every family or culture did any or all of these things). People alive today may have experienced such treatment, and if they did not, they probably heard of it from grandparents or other older relatives who passed along their own narratives. These mistreatments may be recognized as “old-fashioned”, but that may or may not make parents avoid them. They may decide that using “old-fashioned” methods is the socially conservative thing to do and therefore admire those practices, which are basically methods of power assertion.
But there are other possibilities too. Whether or not parents have heard of abusive methods through their own family history, they may be instructed to use such methods by other people. For example, as some readers know, the self-appointed foster parent educator Nancy Thomas has for years recommended power assertion techniques such as limiting the amount and variety of food given to a child, removing most furniture and decorations from the child’s bedroom, and requiring that the child ask permission for the simplest self-care actions like drinking water or using the toilet. Thomas is a persuasive speaker, to the point where a licensed psychologist listened to her suggestions and subsequently had her license revoked after a 12-year-old patient attempted suicide ( see https://childmyths.blogspot.com/2015/03/psychology-license-revoked-become.html). And Thomas is apparently not the only one with a taste for power assertion as a child psychotherapy (see https://childmyths.blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html), as another psychologist’s suggestions seem to have jibed with a couple’s decision to treat their adopted son by limiting his diet, keeping him isolated in his room, and painting his windows black.
There are cases that crop up weekly in which authorities have found children harmed as a result of being treated by “old-fashioned” or Nancy Thomas methods of power assertion. Here are two recent ones:
stories/roy-couple-accused-of- holding-children-captive-in- squalid-home-accepts-plea- deal/
In this case, the adoptive parents of three boys ages 7-11were said to have kept them isolated for as much as thirteen hours a day in a locked room, to have tied or bound them with zip ties and to have duct-taped their mouths, and to have limited their diet. The windows in the room were screwed closed and painted black, and the room had no lights, There were no toilet facilities available to the children while they were locked in the room, and they used a furnace vent for sanitary purposes. (A point to be kept in mind when children are described as intentionally urinating in inappropriate places.) The children were further punished at times by having to eat heavily-salted and cayenne-peppered rice; they were not permitted to drink water after 2 P.M. in spite of this.
If these parents had gone to trial, it might have been possible to find out why they thought these methods were appropriate, but a plea bargain means that we will probably never know any more of the background of this case. My own speculation is that these parents went beyond the “old-fashioned” approach by combining so many elements of power assertion, and adding some nontraditional punishments, for example, painting the windows black. I would guess that this behavior pattern was learned either through some formal instruction or in imitation of others who had been instructed.
In this case, adoptive parents kept a boy, then 5 years old, in an unlighted basement room for 12 hours a day for some months. He had a mattress and a blanket to sleep with. There were no toilet facilities, and if he had to defecate he would put the stool into a hole in the wall. The boy’s diet consisted primarily of carrots, which he had to eat before getting any other food, and if he did not finish the carrots within a time limit he was not allowed other food. The mother stated that she did not know it was against the law to lock a child in a room.
In this somewhat similar case, most of the elements seem to be “old-fashioned” ones , and it is possible that the parents had heard about such treatment of children and imitated it in an informal way. The carrot part is highly unusual, however, and suggests some belief about nutrition derived from an “alternative medicine” source, perhaps on the Internet or through some community or word of mouth communication. The mother’s comment about the legality or otherwise of locking the child in a room suggests a belief that anything that is legal is acceptable in parenting-- or perhaps simply a good deal of confusion about life in general.
Are these cases evidence of Nancy Thomas parenting, or just the “trailing edge” of some old practices? Is Nancy Thomas’s success (and she has had some!) due to her ability to ride the coattails of “the way my granddaddy did it”? Plea bargains and the failure of investigators to follow up on these issues has made it impossible to answer these questions with any certainty. If we knew the answers, though, it might be a great help in preventing these cases.